Inspection Reports for
Claru Deville Nursing Center

Complaint MO249053 triggered the investigation. The complaint involved failure to protect residents from self-harm and unsafe environment. Immediate Jeopardy was identified beginning 02/25/25 and removed on 02/27/25 after corrective actions.

The facility failed to prevent two residents from swallowing AA batteries resulting in emergency room transfers, did not document required 15-minute checks for one resident, and failed to secure hazardous items such as safety razors and hot coffee in unlocked rooms on the secured behavioral unit. Immediate Jeopardy was identified but later removed after corrective actions.

The complaint investigation revealed multiple deficiencies related to resident rights violations, abuse, behavioral health care, infection control, medication administration, and quality assurance.

The facility failed to protect residents' rights on the secured behavioral unit, including inappropriate use of restrictive actions and consequences without proper evaluation or consent. There was physical abuse by staff, inadequate behavioral health care planning, failure to clean respiratory equipment per manufacturer guidelines, medication administration errors, infection control lapses, and lack of an effective QAPI program.

The complaint investigation was triggered by allegations of abuse and neglect on the secured behavioral unit, including physical abuse by a CNA and deprivation of residents' rights and necessary items as punishment. Immediate Jeopardy was identified on 01/14/25 and removed on 01/17/25.

The facility failed to protect residents from abuse and neglect, including physical abuse by a staff member and deprivation of necessary items as a form of punishment. The facility lacked appropriate behavioral health care plans, staff training, and policies for the secured behavioral unit. Residents experienced humiliation, physical harm, and inadequate care interventions.

Complaint # MO00243414 involved a physical altercation between Resident #1 and Resident #2 on 10/10/24, resulting in injuries including redness and cuts to Resident #1's eyes and a bald spot, bruising, and abrasions on Resident #2. Both residents were assessed and treated, with Resident #1 sent to the emergency room and placed on 1:1 supervision after return. The complaint was substantiated by the investigation.

The facility failed to ensure residents' rights to be free from abuse were protected when two residents engaged in a physical fight resulting in injuries. Staff intervened promptly, separated the residents, notified administration, and provided assessments and services. The facility provided staff in-service on abuse and neglect prevention and corrected the deficiency.

Complaint MO00235060 was referenced related to failure to properly notify residents and/or representatives of transfers and bed hold policy.

The facility failed to provide timely and proper written notification to residents and/or their representatives about transfers to hospitals and the bed hold policy for three sampled residents. Additionally, the facility failed to ensure a Registered Nurse was scheduled for at least eight consecutive hours per day, seven days a week, with no RN coverage on six days within the review period.

The facility failed to provide timely written notification to residents and their representatives regarding hospital transfers and bed hold policies for two residents. Additionally, care plans did not address smoking for residents who smoked, and the facility allowed residents to place items on overbed light fixtures, creating an unsafe environment. All deficiencies were assessed as minimal harm affecting few residents.

The complaint investigation found that Licensed Practical Nurse (LPN) A did not assess or report a fall and injury during a behavioral crisis physical intervention on 04/28/2023. The resident complained of pain and inability to bear weight, but LPN A ignored the complaints and did not perform an assessment or notify the Director of Nursing or administration until after the injury was discovered on 04/30/2023. The facility did not report the incident to the state survey agency as required.

The facility failed to ensure Resident #1 was free from neglect when staff did not promptly assess or treat injuries after a fall on 04/28/2023, resulting in fractures to the resident's left tibia, fibula, and humerus. Licensed Practical Nurse (LPN) A failed to assess or report the injury timely, and the facility failed to report the incident to the state survey agency. The investigation led to termination of LPN A and inservicing on abuse and neglect policies.

The visit was complaint-related, triggered by allegations of failure to perform required employee background checks, failure to notify residents or representatives of hospital transfers, failure to prepare residents for transfers, unsafe transfer techniques, and failure to review and act on pharmacy drug regimen recommendations. The complaint was substantiated with findings of minimal harm or potential for harm affecting a few residents.

The facility failed to perform quarterly EDL checks for employees, did not document notification or preparation for hospital transfers for several residents, improperly applied gait belts during resident transfers, and failed to ensure pharmacist recommendations were reviewed and addressed by physicians for multiple residents. The facility census was 63 residents.